Avulsion is a relatively uncommon type of traumatic injury to the permanent dentition

. From a clinical perspective, since avulsions occur infrequently, the average

practitioner will not instinctively know how best to treat each (rare) case that he/she
encounters. Access to quick up to date information such as the IADT guidelines
(http://iadt-dentaltrauma.org) or Andreasens Dental Trauma Guide
(http://dentaltraumaguide.org) is essential so as to offer optimal treatment to each
patient in a timely manner. It occurs most frequently between the ages of 714 years .
The majority of these injuries occur in the maxillary central incisors. Since most
avulsions occur before the patients facial growth is complete it is critical to maintain
the tooth and surrounding bone until facial growth is complete and a relatively
uncomplicated permanent restoration can be made. Therefore, while definitely the
ultimate aim, success does not necessarily require that the tooth is healthy and
functioning for the entire life of the patient. Therefore maintaining the tooth and
surrounding bone for a few years can be considered a successful treatment in the
growing patient. Interestingly most of the injuries occur within a short distance from
home, school or a sports venue . Thus from a theoretical point of view if health
providers in these locations were educated as to the best emergency treatment for
these cases many more successful outcomes would result. When a tooth is avulsed,
attachment damage and pulp necrosis occurs. The tooth is separated from the
socket, mainly due to the tearing of the periodontal ligament that leaves viable
periodontal ligament cells on most of the root surface . In addition, due to the
crushing/scraping of the tooth against the socket, small-localized cemental damage
also occurs. If the periodontal ligament left attached to the root surface does not dry
out, the consequences of tooth avulsion are usually minimal . The hydrated
periodontal ligament cells will maintain their viability, allowing healing with
regenerated periodontal ligament cells when replanted without causing much
destructive inflammation. In addition, since the crushing injury is contained within a
localized area, inflammation stimulated by the damaged tissues will be
correspondingly limited, meaning that healing with new replacement cementum is
likely to occur after the initial inflammation has subsided . However, if excessive drying
occurs before replantation, the damaged periodontal ligament cells will elicit an
inflammatory response over a diffuse area on the root surface. Unlike the situation
described above, where the area to be repaired after the initial inflammatory response
is small, here a large area of root surface is affected that must be repaired by new
tissue. The slower moving cementoblasts cannot cover the entire root surface in time
and it is likely that, in certain areas, bone will attach itself directly onto the root
surface. In time, through physiologic bone remodeling, the entire root will be replaced
by bone; a process which has been termed osseous replacement or replacement
resorption . Pulpal necrosis always occurs after an avulsion injury. While the necrotic
pulp itself is of no consequence (other than the tooth will not continue its
development), the necrotic tissue is extremely susceptible to bacterial contamination.
If revascularization does not occur or effective endodontic therapy is not carried out,
the pulp space will inevitably become infected. The combination of microbes in the
root canal and cemental damage on the external surface of the root results in an
external inflammatory resorption that can be very aggressive. Resorption will continue
as long as the microbes are not removed from the root canal and can lead to the rapid
loss of the tooth .